ADHD

Question 1

What increases the occurrence rate of ADHD?

Answer 1

higher rate if diagnosed in a first-degree relative

etiology is multifactorial

Question 2

What fraction of children diagnosed with ADHD will have a diagnosis in adulthood?

Answer 2

one third

Question 3

What are the risk of leaving ADHD untreated?

Answer 3

• increased risk of substance use and antisocial personality disorder

Question 4

What are the ADHD diagnostic criteria?

Answer 4

• must have at least 6 symptoms present
• for 17+ at least 5 symptoms are required for either of the two specifiers
• several inattentive or hyperactive symptoms must be present prior to age 12
• must be present in two or more settings

Question 5

What are the stimulant dosing considerations?

Answer 5

• dose-response effects are seen in a short-period of time
• weight-based dosing is not necessary
• IR is preferred for pts <16 kg
• avoid giving dose too late in the day
• late afternoon symptoms may require longer-acting formulation
• don’t use two different stimulants (using 2 different dosage forms is fine)

Question 6

What ages is Mydayis approved for?

Answer 6

age 13-17

Question 7

What is the only stimulant patch?

Answer 7

Daytrana (methylphenidate)

Question 8

Which amphetamine is a prodrug?

Answer 8

Vyvanse is converted to dextroamphetamine

Question 9

When should Jornay PM (methylphenidate HCl) be taken?

Answer 9

take dose in the evening between 6:30 pm and 9:30 pm

Question 10

What are the adverse effects of stimulants?

Answer 10

• appetite loss
• sleep disturbances
• increased BP
• decreased growth

Question 11

How can reduced appetite and weight loss be addressed while taking stimulants?

Answer 11

• eat high calorie meal when stimulant effects are low (breakfast, dinner)

Question 12

How can headache be addressed while taking stimulants?

Answer 12

• divide dose
• take with food
• give analgesic

Question 13

How can rebound symptoms be addressed while taking stimulants?

Answer 13

• longer-acting stimulant
• use atomoxetine
• use antidepressant

Question 14

How can irritability or jitteriness be addressed while taking stimulants?

Answer 14

• assess for co-morbid condition
• reduce dose
• consider mood stabilizer or AAP

Question 15

How should hallucinations be addressed while taking stimulants?

Answer 15

• D/C stimulant
• reassess diagnosis
• mood stabilizer or AAP may be considered

Question 16

If there is true concern for sudden cardiac death while taking stimulants, what should be done?

Answer 16

cardiac ECHO

Question 17

What should be monitored while taking stimulants?

Answer 17

• appetite
• behavior
• BP
• growth rate
• HR
• sleep
• ECG (if cardiac risk)

Question 18

What alpha 2 agonists may be used for ADHD?

Answer 18

• guanfacine ER (intuniv) - 3A4 substrate
• clonidine ER (kapvay)

must be tapered if d/c to avoid rebound HTN

Question 19

What norepinephrine reuptake inhibitors may be used for ADHD?

Answer 19

• atomoxetine (Strattera)
• viloxazine (Qelbree)

Question 20

What are the atomoxetine (Strattera) clinical pearls?

Answer 20

• 2D6 substrate
• has weight based-dosing for < 70 kg

Question 21

What are the clinical pearls for viloxazine (Qelbree)?

Answer 21

• capsules - swallow whole or put in applesauce
• 2D6/UGT substrate
• strong 1A2 inhibitor

Question 22

What are the norepinephrine reuptake inhibitor side effects?

atomoxetine, viloxazine

Answer 22

• increased HR and BP
• increased suicidal thinking (boxed warning)

Question 23

What are the alpha 2 agonist side effects?

clonidine, guanfacine

Answer 23

• decreased HR, BP
• orthostasis
• somnolence
• rebound HTN if abrupt d/c

Question 24

Which non-stimulant should have LFT monitoring?

Answer 24

atomoxetine

Question 25

What are the clinical pearls for the use of Bupropion for ADHD?

Answer 25

- not FDA approved for ADHD - 2D6 inhibitor - contraindicated in seizure disorders and eating disorders

Question 26

What concerns are there for using TCAs for ADHD?

Answer 26

- less effective than methylphenidate - cardiac concerns - sudden cardiac death in children, lethal in overdose

Question 27

When may mood stabilizers/ AAPs be used in ADHD?

Answer 27

- May be useful if there is comorbid bipolar disorder, conduct disorder, intermittent explosive disorder - **should not use AAP as monotherapy**

Question 28

What is the first-line treatment recommendation for preschool aged children with ADHD?

Answer 28

parent training in behavior management (PTBM) | PTBM + drug is second

Question 29

What drug is recommended for preschool age children with ADHD?

Answer 29

methylphenidate

Question 30

What are the first line options for elementary through teens for ADHD?

Answer 30

- stimulants | methylphenidate or amphetamine salts

Question 31

What are the second line options for elementary-teens with ADHD?

Answer 31

atomoxetine, guanfacine ER, clonidine ER

Question 32

Which drugs may be used as adjunct treatment?

Answer 32

Only guanfacine ER and clonidine ER have evidence as adjuncts to stimulants

Question 33

What are the treatment guidelines for adults with ADHD?

Answer 33

- first line: methylphenidate (short or long) OR lisdexamfetamine - if no response to one, switch to the other - second line: dextroamphetamine - third line: atomoxetine